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    <title>新增登记</title>

</head>
<body>
<div class="page-container sel_box">
    <!-- 主要填写区域 -->
    <div class="panel-body pb0">
        <div class="row">
            <div class="col-sm-9 col-md-10">
                <div class="row J-checkin-row">
                    <div class="col-sm-4">
                        <div class="form-group pos-relative">
                            <label class="control-label">患者姓名 <span class="asterisk">*</span></label>
                            <div class="form-group input-group">
                                <input type="text" class="form-control J-patient-name" name="name" id="patient_name" value="" required="" autocomplete="off">
                                <span class="input-group-btn">
									<button type="button" class="btn btn-default btn-find J-btn-search" data-toggle="modal"><i class="fa fa-search"></i></button>
								</span>
                            </div>
                            <div class="search-block hidden J-search-name">
                                <div class="tips">请选择患者或继续新增</div>
                                <ul class="J-search-list"></ul>
                            </div>
                        </div>
                    </div>
                    <div class="col-sm-2 col-md-2">
                        <div class="form-group">
                            <label class="control-label">出生年月 <span class="asterisk">*</span></label>
                            <input class="form-control realbirth J-listerner J-checkin-birthday J-birthday-only" placeholder="____年__月__日" name="birth_date" id="appDate" type="text" value="" required="">
                        </div>
                    </div>
                    <div class="col-sm-2 col-md-2">
                        <div class="form-group">
                            <label class="control-label">年龄 <span class="asterisk">*</span></label>
                            <input class="form-control realage J-checkin-age" placeholder="__岁" name="age" id="J-checkin-age" type="text" value="">
                        </div>
                    </div>
                    <div class="col-sm-4 col-md-4">
                        <div class="form-group">
                            <label class="control-label">性别 <span class="asterisk">*</span></label>
                            <div class="row mt10">
                                <div class="col-xs-3 col-sm-4 col-pad-sm">
                                    <div class="rdio rdio-default">
                                        <input type="radio" name="sex_code" id="radioDefault1" value="1" required="" class="J-listerner">
                                        <label for="radioDefault1">男</label>
                                    </div>
                                </div>
                                <div class="col-xs-3 col-sm-4 col-pad-sm">
                                    <div class="rdio rdio-default">
                                        <input type="radio" name="sex_code" id="radioDefault2" value="2" required="" class="J-listerner">
                                        <label for="radioDefault2">女</label>
                                    </div>
                                </div>
                                <div class="col-xs-3 col-sm-4 col-pad-sm">
                                    <div class="rdio rdio-default">
                                        <input type="radio" name="sex_code" id="radioDefault0" value="3" required="" class="J-listerner">
                                        <label for="radioDefault0">不详</label>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="row">
                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="control-label">手机号</label>

                            <input type="number" name="mobilenumber" value="" class="form-control cellphone J-phone ime-mode">
                        </div>
                    </div>
                    <div class="col-sm-2 col-md-2">
                        <div class="form-group">
                            <label class="control-label">住址</label>
                            <select class="form-control input-sm mt0 J-location-pro J-listerner" data-placeholder="请选择" name="province"><option value="">请选择</option><option value="110000">北京</option><option value="120000">天津</option><option value="130000">河北</option><option value="140000">山西</option><option value="150000">内蒙古</option><option value="210000">辽宁</option><option value="220000">吉林</option><option value="230000">黑龙江</option><option value="310000">上海</option><option value="320000">江苏</option><option value="330000">浙江</option><option value="340000">安徽</option><option value="350000">福建</option><option value="360000">江西</option><option value="370000">山东</option><option value="410000">河南</option><option value="420000">湖北</option><option value="430000">湖南</option><option value="440000">广东</option><option value="450000">广西</option><option value="460000">海南</option><option value="500000">重庆</option><option value="510000">四川</option><option value="520000">贵州</option><option value="530000">云南</option><option value="540000">西藏</option><option value="610000">陕西</option><option value="620000">甘肃</option><option value="630000">青海</option><option value="640000">宁夏</option><option value="650000">新疆</option><option value="710000">台湾</option><option value="810000">香港</option><option value="820000">澳门</option><option value="900000">国外</option></select>
                            <input type="hidden" class="J-location-pro-name" name="province_name" value="">
                        </div>
                    </div>
                    <div class="col-sm-2 col-md-2">
                        <div class="form-group">
                            <label class="control-label">&nbsp;</label>
                            <select class="form-control input-sm mt0 J-location-city J-listerner" data-placeholder="请选择" name="city">
                                <option value="" selected="selected">

                                </option>
                            </select>
                            <input type="hidden" class="J-location-city-name" name="city_name" value="

								">
                        </div>
                    </div>
                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="control-label">&nbsp;</label>
                            <input type="text" name="address" value="" placeholder="详细地址" class="form-control J-listerner">
                        </div>
                    </div>
                </div>
                <div class="panel-heading bgfc pt20 pl0 green cursor-pointer J-show-detail" data-type="info">
                    <h4 class="panel-title green pull-left">更多信息</h4><i class="fa fa-angle-down font22 mr10 admin-point-style ease mt2 J-detail-icon"></i>
                </div>
                <div class="panel-body bgfc pd0 pb20 border-bottom-e7 hidden J-detail-box">
                    <div class="row">
                        <div class="col-sm-4">
                            <div class="form-group">
                                <label class="control-label">病人卡号</label>
                                <input type="text" name="card_no" value="" class="form-control ime-mode J-listerner">
                            </div>
                        </div>

                        <div class="col-sm-4 J-source-box">
                            <div class="form-group">
                                <label class="control-label">患者来源</label>
                                <input type="hidden" value="" class="J-source">
                                <select class="form-control input-sm mt0 J-source-select J-listerner" data-placeholder="请选择" name="source">
                                    <option selected="selected" value="">请选择</option><option value="0">无</option><option value="1">亲友推荐</option><option value="2">微信</option><option value="3">媒体报道</option><option value="4">微博</option><option value="5">其他</option><option value="6">附近居民</option><option value="7">员工及家属</option><option value="8">活动推广</option><option value="10012">张三</option><option value="10013">李四</option><option value="10016">医生亲属</option></select>
                            </div>
                        </div>
                        <div class="col-sm-2 hidden J-othersource-box">
                            <div class="form-group">
                                <label class="control-label">&nbsp;</label>
                                <input type="text" name="source_name" value="" class="form-control J-other-source J-listerner">
                            </div>
                        </div>
                        <div class="col-sm-4 J-module-control" data-modules="33">
                            <div class="form-group">
                                <label class="control-label">会员类型</label>
                                <select class="form-control input-sm mt0 J-listerner" data-placeholder="请选择" name="member_type" data-value=""><option selected="selected" value="">请选择</option><option value="1">一级会员</option><option value="2">二级会员</option><option value="4">三级会员</option><option value="5">金卡会员</option><option value="6">银卡会员</option><option value="7">钻石卡会员</option><option value="9">免费券</option><option value="15">学生</option><option value="16">居民</option><option value="17">高级会员</option><option value="18">药品折扣会员</option><option value="19">再消费会员</option><option value="32">特权会员</option><option value="36">9折会员</option><option value="37">VIP会员</option><option value="38">十次客户</option><option value="39">参保学生</option><option value="43">钻石VIP高级内部总统级优惠铂金价</option><option value="46">存善会员</option><option value="47">体验用户</option><option value="48">中国银行</option><option value="51">金卡会员打折版</option><option value="52">7天内复诊会员</option><option value="53">VVIP M01</option><option value="54">普通会员</option><option value="56">初级会员</option><option value="57">金卡卡会员</option><option value="59">VIP6</option><option value="61">推拿卡会员</option><option value="63">健康会员卡</option><option value="64">小草笑嘻嘻会员类型管理</option><option value="68">至尊专属黑卡</option><option value="69">至尊会员卡</option><option value="70">至尊超级专享会员PLUS</option></select>
                            </div>
                        </div>
                    </div>
                    <div class="row">
                        <div class="col-sm-4">
                            <div class="form-group">
                                <label class="control-label">身份证号</label>

                                <input type="text" name="id_no" value="" class="form-control isPid ime-mode J-listerner">
                            </div>
                        </div>
                        <div class="col-sm-4">
                            <div class="form-group">
                                <label class="control-label">民族</label>
                                <input type="hidden" value="" class="J-nation">
                                <select class="form-control input-sm mt0 J-listerner" id="j_selectNation" data-placeholder="请选择" name="nation">
                                    <option value="">请选择</option>
                                    <option value="1">汉族</option><option value="2">少数民族</option><option value="3">中国香港</option><option value="4">中国澳门</option></select>
                            </div>
                        </div>
                        <div class="col-sm-4">
                            <div class="form-group">
                                <label class="control-label">婚姻状况</label>
                                <select class="form-control input-sm mt0 J-listerner" data-placeholder="请选择" name="marriage">
                                    <option value="">未选择</option>
                                    <option value="1">未婚</option>

                                    <option value="2">已婚</option>
                                    <option value="3">离异</option>
                                    <option value="4">丧偶</option>

                                </select>
                            </div>
                        </div>
                        <div class="col-sm-4 hidden">
                            <div class="form-group">
                                <label class="control-label">预约号</label>
                                <input type="number" name="reservation_id" value="" class="form-control J-listerner">
                            </div>
                        </div>
                    </div>
                    <div class="row">
                        <div class="col-sm-4 J-job-box">
                            <div class="form-group">
                                <label class="control-label">职业</label>
                                <input type="hidden" value="" class="J-job">
                                <select class="form-control J-job-select input-sm mt0 J-listerner" id="j_selectJob" data-placeholder="请选择" name="job">
                                    <option value="">请选择</option>
                                    <option value="1">医务人员</option><option value="2">农民</option><option value="3">商人</option><option value="4">军人</option><option value="5">教师</option><option value="6">学生</option><option value="7">公务员</option><option value="8">公司职员</option><option value="9">工人</option><option value="10">媒体</option><option value="11">无</option><option value="12">其他</option></select>
                            </div>
                        </div>
                        <div class="col-sm-2 hidden J-otherjob-box">
                            <div class="form-group">
                                <label class="control-label">&nbsp;</label>
                                <input type="text" name="job_name" value="" class="form-control J-other-job J-listerner">
                            </div>
                        </div>
                        <div class="col-sm-4">
                            <div class="form-group">
                                <label class="control-label">工作单位</label>
                                <input type="text" name="company" value="" class="form-control J-listerner">
                            </div>
                        </div>
                        <div class="col-sm-4">
                            <div class="form-group">
                                <label class="control-label">邮箱</label>
                                <input type="email" name="email" value="" class="form-control email J-listerner">
                            </div>
                        </div>
                    </div>
                    <div class="row">
                        <div class="col-sm-8">
                            <div class="form-group">
                                <label class="control-label">备注</label>
                                <input type="text" name="remark" value="" class="form-control J-listerner">
                            </div>
                        </div>

                    </div>
                </div>
                <div class="panel-heading border-none bgfc pt20 pl0">
                    <h4 class="panel-title">接诊信息</h4>
                </div>
                <div class="panel-body bgfc-pd0 pd0">
                    <div class="row">
                        <div class="col-sm-4">
                            <div class="form-group">
                                <label class="control-label">科室 <span class="asterisk">*</span></label>
                                <select class="form-control input-sm mt0 J-reservation-type-select" data-placeholder="请选择" name="firstvisit" required="">
                                    <option selected="selected" value="1">儿科</option>
                                    <option value="2">眼科</option>
                                    <option value="3">妇科</option>
                                    <option value="4">内科</option>
                                </select>
                            </div>
                        </div>
                        <div class="col-sm-4 col-md-4">
                            <div class="form-group">
                                <label class="control-label">接诊类型 <span class="asterisk">*</span></label>
                                <select class="form-control input-sm mt0 J-reservation-type-select" data-placeholder="请选择" name="firstvisit" required="">
                                    <option selected="selected" value="1">初诊</option>
                                    <option value="2">复诊</option>
                                    <option value="3">儿童体检</option>
                                    <option value="4">成人体检</option>
                                </select>
                            </div>
                        </div>

                    </div>
                </div>
            </div>
            <div class="col-sm-3 col-md-2">
                <div class="form-group" id="crop-avatar" data-url="/Index/uploadImage">
                    <div class="J_image_upload mr0">
                        <div class="image-select J_image_select avatar-view empty" data-original-title="" title="">
                            <div class="image-preview">

                                <img src="public/static/h-ui.admin/images/unknown-avatar.png" alt="">

                            </div>
                            <div class="image-upload">
                                <input type="file" name="files1[]" id="f-image-upload" accept="image/*">
                                <!-- <input type="hidden" name="image_data" class="J-image-data" value=""> -->
                                <input type="hidden" name="image" class="input-upload J-listerner" value="">
                                <a class="btn btn-default btn-sm">上传头像</a>
                            </div>
                        </div>
                    </div>
                </div>
                <!-- 上传头像 -->
            </div>

            <!-- start上传头像组建 -->
            <div class="modal fade" id="avatar-modal" aria-hidden="true" aria-labelledby="avatar-modal-label" role="dialog" tabindex="-1">
                <div class="modal-dialog modal-lg">
                    <div class="modal-content">
                        <div class="avatar-form" action="" enctype="multipart/form-data" method="post">
                            <div class="modal-header">
                                <button class="close" data-dismiss="modal" type="button">×</button>
                                <h4 class="modal-title" id="avatar-modal-label">上传图片</h4>
                            </div>
                            <div class="modal-body">
                                <div class="avatar-body">
                                    <div class="row">
                                        <div class="avatar-upload col-sm-12">
                                            <div class="input-group">
												<span class="input-group-btn">
													<div class="btn btn-default image-preview-input">
														<span class="glyphicon glyphicon-folder-open"></span>
														<span class="image-preview-input-title">选择文件</span>
														<input class="avatar-src" name="avatar_src" type="hidden">
														<input class="avatar-data" name="image_data" type="hidden">

														<input name="is_protected" value="true" type="hidden">
														<input name="owner_type" value="1" type="hidden">
														<input name="type" value="1" type="hidden">
														<input name="media_type" value="image" type="hidden">
														<input class="avatar-input" id="avatarInput" name="uploadFile" type="file" accept="image/*">
													</div>
												</span>
                                                <button type="button" class="btn btn-white J-btn-camera ml10 black"><i class="fa fa-camera"></i> 拍照上传</button>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="row">
                                        <div class="col-md-9">
                                            <div class="avatar-wrapper J-show-pic"></div>
                                            <video style="display:none;" class="avatar-wrapper" id="video"></video></div>
                                        <div class="col-md-3">
                                            <div class="avatar-preview preview-lg"></div>
                                            <div class="avatar-preview preview-md"></div>
                                            <div class="avatar-preview preview-sm"></div>
                                        </div>
                                    </div>
                                    <div class="row avatar-btns">
                                        <a class="btn btn-primary btn-block avatar-save" type="javascript:;">确定</a>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
            </div>
            <!-- end上传头像组建 -->
        </div>
    </div>
    <!-- 添加家庭成员 -->
    <div class="panel-heading bgfc pt20 green cursor-pointer border-none J-show-detail" data-type="family">
        <h4 class="panel-title green pull-left">添加家庭成员</h4><i class="fa fa-angle-down font22 mr10 admin-point-style ease mt2 J-detail-icon green"></i>
    </div>
    <div class="panel-body pb0 J-family-box J-detail-box hidden">
        <input type="hidden" name="type" value="multi">
        <input type="hidden" id="J-del-id" name="del_id" value="">


        <div class="row family-list J-checkin-row">
            <input type="hidden" name="id[]" value="">
            <input type="hidden" name="family_id[]" value="">
            <div class="col-sm-12">
                <div class="row">
                    <div class="col-sm-2 w13">
                        <div class="form-group">
                            <label class="control-label">成员关系 <span class="asterisk">*</span></label>
                            <select class="form-control input-sm mt0 J-member-select" data-placeholder="请选择" name="family_ship[]"><option value="">请选择</option><option value="101">父亲</option><option value="102">母亲</option><option value="103">配偶</option><option value="104">儿子</option><option value="105">女儿</option><option value="106">（外）祖父/母</option><option value="107">（外）孙子/女</option><option value="110">朋友</option><option value="111">其他</option><option value="112">兄弟姐妹</option></select>
                        </div>
                    </div>
                    <div class="col-sm-2 w15">
                        <div class="form-group pos-relative">
                            <label class="control-label">姓名 <span class="asterisk">*</span></label>
                            <div class="form-group">
                                <input type="text" value="" class="form-control sub-member J-family-patient-name" name="family_name[]" autocomplete="off">
                            </div>
                            <div class="search-block hidden J-family-search-name">
                                <div class="tips">请选择患者或继续新增</div>
                                <ul></ul>
                            </div>
                        </div>
                    </div>
                    <div class="col-sm-2 w10">
                        <div class="form-group">
                            <label class="control-label">性别 <span class="asterisk">*</span></label>
                            <select class="form-control input-sm mt0 sub-member" name="family_sex_code[]" data-placeholder="请选择">
                                <option value="" selected="selected">请选择</option>
                                <option value="1">男</option>
                                <option value="2">女</option>
                                <option value="3">不详</option>
                            </select>
                        </div>
                    </div>
                    <div class="col-sm-2 col-md-1 w13">
                        <div class="form-group">
                            <label class="control-label">出生年月 <span class="asterisk">*</span></label>
                            <input class="form-control realbirth J-birth-date sub-member J-checkin-birthday" placeholder="____年__月__日" name="family_birth_date[]" type="text" value="">
                        </div>
                    </div>
                    <div class="col-sm-1 col-md-1 w8">
                        <div class="form-group">
                            <label class="control-label">年龄 <span class="asterisk">*</span></label>
                            <input class="form-control realage J-checkin-age" placeholder="__岁" name="age" type="text" value="">
                        </div>
                    </div>
                    <div class="col-sm-2 w13">
                        <div class="form-group">
                            <label class="control-label">手机号 <span class="asterisk">*</span></label>
                            <input type="number" value="" class="form-control cellphone" name="family_mobilephone[]">
                        </div>
                    </div>

                    <div class="col-sm-2">
                        <div class="form-group">
                            <label class="control-label">绑定微信</label>
                            <div class="form-group input-group">
                                <input type="text" class="form-control" readonly="" name="family_wechatid[]" value="">
                                <span class="input-group-btn">
										<button type="button" class="btn btn-default btn-find J-family-qrcode J-wechat-text">绑定</button>
									</span>
                            </div>
                        </div>
                    </div>

                    <div class="col-sm-1 w11">
                        <div class="form-group">
                            <label class="control-label display-block"> </label>
                            <a class="btn input-sm mt0 btn-white J-btn-delete-family hidden"><i class="fa fa-minus"></i></a>
                            <a class="btn input-sm mt0 btn-white J-btn-add-family"><i class="fa fa-plus"></i></a>
                        </div>
                    </div>
                </div>
            </div>
            <div class="col-sm-3 col-md-2"></div>
        </div>

    </div>
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